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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003893
Report Date: 11/02/2021
Date Signed: 11/02/2021 02:58:17 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:ROSEHAVEN 1FACILITY NUMBER:
306003893
ADMINISTRATOR:JAYALAKSHMI PICHIKAFACILITY TYPE:
740
ADDRESS:203 CALLE DEL JUEGOTELEPHONE:
(949) 366-2599
CITY:SAN CLEMENTESTATE: CAZIP CODE:
92672
CAPACITY:6CENSUS: 3DATE:
11/02/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Dominga Santillian and Jay PichikaTIME COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and granted entry into the facility by Caregiver Dominga Santillian and explained the reason for the visit. Administrator/ Licensee Jay Pichika arrived during the visit.

At 10:00 AM, LPA toured the facility with Caregiver Santillian. Administrator Pichika joined the tour in progress. Facility has three residents in care during today's visit. LPA observed residents relaxing in their rooms or in common areas. Facility appears clean and sanitary. All resident's rooms had the required elements as well as restrooms stocked with soap/ sanitizer. At 10:10 AM, LPA observed a floor tile coming up in the master suite. Hand washing signs are posted throughout the restrooms. LPA observed the screening/ sanitizing station in the entrance of the facility. Facility takes resident temperatures daily and documents. Facility has covid precaution postings as well as most required department postings. Administrator Pichika has an administrator certificate that expired on 09/13/2019. LPA observed a bed and discarded items sitting on the driveway as well as an ramp needing repair (photos). LPA toured the kitchen and observed ample food supply as well as emergency food and water. At 10:20 AM, LPA observed a broken cabinet door in the kitchen as well as missing molding on the top of kitchen cupboards. Facility has completed the mitigation plan and the plan has been approved. LPA observed the first aid kit contained all required items and medications are stored secured in a locked cabinet. LPA toured the outside grounds and observed the outside visitation area. LPA observed a patio set with broken cushions and table decorations are peeling off the table. Facility has ample supply of PPE and cleaning supplies. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation. All staff and residents are vaccinated for Covid-19. LPA reviewed all files which contained required documentation including emergency information and updated physician reports.
LPA consulted with Administrator regarding the importance of maintaining an ample supply of N95 masks on-site at all times.
Based on the observations made during today's visit, CONTINUED ON LIC 809C DATED 11/02/2021
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: ROSEHAVEN 1
FACILITY NUMBER: 306003893
VISIT DATE: 11/02/2021
NARRATIVE
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the following violations are being cited per California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted and a copy of this report as well as appeal rights were discussed and provided with facility representative.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ROSEHAVEN 1
FACILITY NUMBER: 306003893
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/02/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87407(a)
Administrators shall complete at least forty (40) classroom hours of continuing education during each two (2)-year certification period...


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed Licensee's administrator certificate expired 09/13/2019. This poses a potential health and safety risk to persons in care.
POC Due Date: 11/16/2021
Plan of Correction
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Licensee to forward proof of initiatiating the process to renew certificate and forward proof to LPA by POC due date.
Type B
Section Cited
CCR
87303(a)
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (observation, the licensee did not comply with the section cited above. LPA observed discarded items on front driveway, tile coming up in master suite, a broken patio set in backyard, broken cupboard in kitchen, an entry ramp needing repair as well as missing molding on kitchen cupboard. This poses a potential health and safety risk to persons in care.
POC Due Date: 11/16/2021
Plan of Correction
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Licensee to repair/ replace noted items and forward proof to LPA by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2021
LIC809 (FAS) - (06/04)
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